The Greens may have something to say, but Natalie Bennett’s performances put them in a double bind

Natalie Bennett has given a second terrible interview, this time to LBC on the topic of housing. (The first was on Citizen’s Income to the Sunday Politics.)

Yesterday’s mishap is terrible from both a content and a style point of view: content because she doesn’t appear to know basic numbers behind her party’s policy on housing; style because the pauses, coughs, erms, and “right, yes”-es don’t convey any confidence to listeners.

There’s another reason why this is terrible, though: the Green Party might have something different to say when it comes to politics. This is, after all, the reason why Bennett is being interviewed on LBC and the Daily Politics and why so many people are therefore aware of how badly her interviews are going. But we don’t know what it is the Green Party has to say because everyone is focusing on what a bad job they are doing in saying it.

Where does this leave us?

At the individual leve, I don’t know Bennett well enough to understand whether these interviews are just a blip or whether she isn’t necessarily cut out to be leader of a political party.

At the party level I can’t help but think that the Greens need more political professionals behind them – like strategists, media managers, policy people etc. – to try and get their house in order and prevent / minimise this type of thing happening again and again.

The irony, of course, is that whilst having more of these things might make them more effective it would also make them a bit more like the bigger political parties they’re currently the antidote to.

It’s a double-bind, and the quality of our political debate may be the worse for it.

Following the money can support personalised payment mechanisms: exploring the health payment system

Alternative Guide to the NHS - from the King's Fund
Alternative Guide to the NHS – from The King’s Fund

Most discussion about health and social care is about how much money there is(n’t) in the system. Relatively little attention is given to how the money in health and social care flows through that system.

This post shares some extended thoughts on what we know about the payment system in health, how this has been applied to mental health and how, despite potential perils, we can use current and future payment system changes and extensions into social care to support personalisation.

It is a bit dense in places, but it hopefully gives a useful grounding in the payment system for those who’d like to know a bit more about it and the opportunities (and difficulties) it presents. The post is broken up into 3 parts: (1) How the health payment system works; (2) How the health payment system has been extended into mental health; and (3) The perils and opportunities of moving a health payment system into social care.

I. The health payment system

To understand how a system works a good rule of thumb is to follow the money. In large parts of the health service this is pretty easy to do because of the payment/tariff system (which used to be known as “Payment by Results”[1]).

The core building blocks of the payment system are currencies and tariffs. The currency defines the unit of healthcare for which a payment is made (i.e. the ‘what’, such as a hip replacement or cataract operation) and the tariff defines ‘how much’ for each currency (i.e. what will be paid).

Thus, for any person receiving any treatment in certain settings, the following basic process is followed:

  • Treatment occurs
  • Treatment is coded using separate classification systems for diagnoses and interventions
  • Grouping of treatment – a Healthcare Resource Grouping (HRG) is allocated based on clinical codes and other patient data
  • Tariff – The tariff price depends on HRG and type of admission, and there are a variety of tariff adjustments made
  • Payment – standard monthly payments are made in advance, based on activity plan. Actual activity transmitted from provider to commissioners adjusts these payments up or down

In its introduction to the payment system (from 2013) the Department of Health produced this useful diagram to explain the broad principles of how the payment system applied to Mrs Smith having twins, Mr Jones having an emergency hip replacement and how much their treatment costs.

PbR worked examples
Click to enlarge

To get to this point the payment system in health has evolved a lot since it was first introduced in 2003/4. That year this type of payment system made up around £100m of health spending (some 0.2% of relevant commissioner allocations); by 2011/12 it made up £28.9bn of health spending (32.4% of relevant commissioner allocations).

II. Extending the health payment system into mental health

For things that are relatively well defined (such as giving birth or hip replacements), a currency/tariff system is relatively easy to define. This is partly to do with how well the evidence base is developed: in health, NICE pathways exist which outline exactly what should be done and when. (Here’s the pathway for multiple pregnancies and here’s the one for hip fractures.)

What if, though, we apply similar principles to areas where definitions or boundaries aren’t so easy to come across: mental health and social care?

In mental health, a lot of effort has already been made in this direction. All of the various mental health problems that people can have are divided up into 21 ‘clusters’ – a way of grouping people with mental health problems according to their needs, based on descriptions of characteristics of people who are assumed to have similar mental health support needs, and the level of resource needed to meet these needs. In mental health, these ‘clusters’ are the currency (i.e. the ‘what’, or the equivalent of hip replacements etc.).

If this were to follow the twins / hip replacement example, we would then allocate an amount of money to the treatment of someone in a particular cluster and all would, we hope, be sorted. In mental health, though, there are a whole range of other factors that affect what is or isn’t included in someone’s treatment. These factors include (but are not limited to):

  • Mental health episodes are more difficult to define and diagnoses are less clear-cut
  • There is less clinical consensus on optimal care pathways, making cost variations more pronounced. Even if there was a consensus on pathways, mental health support is not consistently available across the country, including where some types of support simply aren’t available
  • Interrelationships with physical health are complex, with mental health problems having a substantial impact on health conditions
  • Mental health problems typically imposes costs and benefits in non-health sectors
  • There are shortcomings in both the availability and quality of activity data for mental health, which make very difficult the development of robust remuneration
  • The evidence base for mental health interventions is far less developed than for traditional health interventions
  • The money that meets different elements of the support comes from different sources, most notably health and social care pots of money.

What this list of factors means is that the pathway and the payment are much harder to determine in mental health.

Efforts have been underway since 2010/11 to both define the typical pathways associated with each cluster and the prices that might be attached to them. Progress is very mixed, though: clustering people with mental health problems is required by central government, but payment isn’t yet compulsory – local areas can develop their own ways of arranging payment. Furthermore, the extent to which the new payment system in mental health has changed the nature of activity and the differences it has made in people’s lives is a moot point. A recent survey by the Healthcare Financial Management Association (HFMA) (pdf) shared the views of health finance managers on progress regarding the mental health payment system. Findings included:

  • 84% reported commissioner understanding of the mental health payment system to be very poor, poor or fair
  • 60% reported cluster-based activity as having “no” financial impact
  • 70% reported that they still operated under a block contract with commissioners with a shadow tariff.

III. The opportunities and perils of moving a health payment system into social care

As it is in mental health, so the picture would be (even) more complicated in social care.

It isn’t yet the case that formal segmentation of the care population (to create ‘currencies’ and ‘clusters’), associated care pathways and prices have been developed. What we are starting to see, though, is a more concerted effort to define what we might typically expect from a social care pathway; this is mainly been driven through the NICE Collaborating Centre for Social Care (guidelines are being produced, for example, on the topics of home care and reablement). The drive to integration will also bring social care far more, perhaps fundamentally, under the aegis of agencies like Monitor and NHS England, who are jointly responsible for the payment system in health. CQC is, of course, already a joint regulatory body that operates across both health and social care.

In my personal view, and drawing on the experience in mental health, there are both perils and opportunities of bringing a health-type payment system into social care.

The biggest peril is that social care could be the less richer for such a payment system. This lost richness would be made up of a more medical focus in social care, painting a more black and white picture of people than the complexity and range of social care represents. Health is making attempts to shift away from this viewpoint (see, for example, the Coalition for Collaborative Care, Co4CC), but the experience in mental health suggests the practice of anything other than medical thinking related to payment systems is very hard to do.

There are, though, 4 positive opportunities we can take from any current or future attempts to develop currencies and payments in social care.

  1. Such a payment system begins to bridge the gaps (professional, language etc.) people from different professional backgrounds bring. Health and social care professionals start from very different technical positions, though aren’t different in what they seek to do for and with the people they support. Thinking about pathways and payments and trying to put them in place enables people across the piece to come together for a common goal, starting from where they currently respectively are
  2. Building standard national mechanisms won’t, I think, work. But providing a strong requirement to develop a local model, backed up by excellent guidance, support, encouragement and sharing of learning can help areas to create strong local health and social care economies through their common work to develop (if not produce) pathways and payments
  3. Attempts to build the picture will show where evidence is most needed in social care (and health). I am by no means advocating the unrealistic position that we should only spend money on models/interventions/supports backed up by ‘gold-standard’ evidence; but I am saying that knowing where more appropriate evidence is needed will help us to ensure more of what is available through social care is as effective as it can be in supporting people
  4. Perhaps the most exciting opportunity is that developing payments systems like this does much of the heavy lifting in identifying how much money is associated with the care and support of an individual. Even more exciting is the idea that such information would incorporate both health and social care provision. Once the amount is known it is then easier for an individual to take that resource as a Personal Budget / Personal Health Budget, with all the benefits we know are associated with this. After such work, the natural foundations for things like Integrated Personal Commissioning are then in place.

These are 4 reasons I could get behind.

Reforms in health and social care aren’t always renowned for their subtlety. What I’ve therefore endeavoured to do in this post is show how there are always opportunities in reforms – in this case, the payment system, with its currencies and tariffs  – that can be used to support a whole range of ends. Here, following the money provides a chance to bring health and social care people together and do much of the heavy lifting that personalisation through, for example personalised payment mechanisms, requires. Though this isn’t without its perils, as the experience in mental health shows, the opportunities aren’t too bad either.


[1] – Back in 2013 I wrote an introductory guide to what was then Payment by Results in mental health. Though some of the technical information has been superseded by development since then (and on which a publication is forthcoming) most of the information in the guide remains useful. You can find it here.

Self-Directed Support in mental health: what can you do differently?

Permission to DreamBelow is a post written for Outside the Box in Scotland, ahead of their Permission to Dream event next month on how people across Scotland have been getting on over the first year of Self-Directed Support.

Last year, Outside the Box ran a series of great events on what the new Self-Directed Support Act (2014) might mean for mental health in Scotland. The events brought together a range of people from across the mental health system: people who use services, families, carers and representative organisations; social workers; team managers; commissioners and providers. As a result, the conversations were rich and engaging.

One thing that struck me during people’s discussions was that very few people thought the health and social care system was working for people with mental health problems as it was. This feeling wasn’t limited to just social care outcomes and people’s mental health themselves: it included what opportunities people with mental health problems had in areas of life like housing, employment and fairly accessing welfare support.

The question before everyone was clear: how do we make things better? The Self-Directed Support Act 2014 is a major part of the answer. The Act aims to empower people to have control and responsibility over how their care and support is arranged, including offering people different choices for organising their care. (You can find out more information about the Act on the Getting There website.)

Henry Ford famously said: “If you always do what you’ve always done, you’ll always get what you’ve always got.” The Act is therefore a really good chance to do something differently. A really interesting question for everyone with an interest in the mental health system to ask themselves is: what can they do differently as a result of the new SDS Act?

Here are a few suggestions (you can find more in this practice paper on the Getting There website):

  • For people who use services, this could mean finding out more about the Self-Directed Support Act so you know what your rights are and how to access the support available to live the life you want.
  • For a frontline practitioner, this could mean working in partnership with a person rather than thinking of them as someone to assess and put in place a package for. This could include thinking together beyond the usual menu of ‘traditional’ services people might access.
  • For team managers, it could mean creating regular opportunities for their team members to talk about the good things they’ve done as a result of self-directed support, or to talk about the challenges this new way of working brings and enabling people to support each other to address those challenges.
  • For people who commission services, it could mean knowing how much money was spent on what types of mental health support and then explicitly aiming to change this over the next 3 years, responding to the different choices that people make.

The pressure and constraints that currently exist in the mental health system sometimes lead people to think they can’t do anything themselves to make things better – it’s “beyond their control”. The places that make the most progress are those where as many people as possible take the opportunity to do something different in their part of the system and give it a go – no matter how small a change they personally make. Let’s all of us use the opportunity of the Self-Directed Support Act to help improve the lives of people with mental health problems.

#SCIEroundtable on community-led social care

Image by Nigel Wedge on Flickr
Image by Nigel Wedge on Flickr

The Social Care Institute for Excellence (SCIE) yesterday hosted an event on community-led social care. It’s the first in a series of events they will be hosting over the coming months, and if this one is anything to go by the rest will be well worth attending.

It’s not unusual to have speakers at events make you stop and think. It is unusual, though, for every speaker and all subsequent contributors to share views that are of a consistently high quality, offer fresh insights, don’t fall back on lazy or repeated wisdom, and all of whom stick to time. Somehow, though, that’s what was managed yesterday!

It wouldn’t do justice to the richness of the discussion for me to attempt to summarise what was talked about. Further details will, I think, be shared; but here are 3 things I particularly enjoyed in yesterday’s discussion.

  1. We must spend more time and effort thinking about “scaling across” instead of scaling up. Another way of thinking about this is about spread rather than size per se. This reflection came from people recognising that approaches which are working may work precisely because their characteristics work at a certain scale. By changing the scale you then affect the characteristics. Rather, then, than fundamentally changing the size (through scaling up) the smarter thing to do is think how to replicate (scale across, or spread).
  2. The ingredients of what makes stuff work are, by now, relatively familiar (though by no means regularly recognised or understood). These include trust, good relationships, good leadership at all levels, a shared vision etc. But more than this, the way in which these ingredients are brought together – the recipe – matters just as much. What’s more, the recipe may change from area to area, and whilst the ingredients are necessary, they aren’t sufficient. This leads to the idea (and switching metaphors) of creating an eco-system in health and social care (say), rather than just a system. This gives a better view of the range, diversity and strength of connections needed between all parts of the system, as well as thinking about what those connections are between.
  3. Paul Streets from Lloyds Bank Foundation shared what they call the “3 tyrannies” of commissioning: specifications, standards and scale. I shall be liberally repeating this!

For what it’s worth, my own reflection was on this idea of the “deficit of candour” in public services. Whilst there aren’t honest conversations about what public services can and can’t achieve in terms of people’s expectations and what they’re willing to pay for them, it becomes harder to create the conditions in which an eco-system could flourish. For me, one way of bridging this is by highlighting what rights people have: if people are equipped with this knowledge, not only will it help to rebalance the existing distribution of power between people and professionals, but also help people to think how they themselves can use their identity and capabilities to contribute themselves to the eco-system.

Thanks to everyone involved in yesterday’s stimulating debate, and thanks for SCIE for organising such a great session. The hashtag for the roundtable is #SCIEroundtable.

For politicians it’s far less #timetotalk and much more #timetoact on #mentalhealth

TTC Supporting Logo Red-1Today is Time to Talk day, when people are being encouraged to by taking 5 minutes out of their day to have a conversation about mental health.

Time to Talk day is one of the major points of the year for the Time to Change campaign – England’s biggest programme to challenge mental health stigma and discrimination. Time to Change has done a terrific job since it started in 2007 and has had a demonstrable, considerable effect on people’s attitudes towards mental health.

I’m fully supportive of the Time to Change campaign.

One thing I struggle with, though, is seeing politicians – particularly Ministers – blithely adding their support to such campaigns.

The reason, you see, is this:

MH spending 0809 to 1314 h

The red box shows real-terms spending on mental health has decreased year-on-year since 2009/10 [1] – from £1.32billion in 2009/10 to £1.10billion in 2013/14.

Now, I understand the difficulties that politicians, including Ministers, have in discharging their public duties. They want to use their position to promote good campaigns, or to provide direction to something they hope will bring along the public, and this often involves talking about things that aren’t necessarily being talked about.

But when the reality of their actions is so far away from their warm words – as documented in mental health virtually every week over the last 4.5 years, and as symbolised by the real-terms cut in mental health budgets – it becomes pretty hard to swallow.

It’s certainly #timetotalk about #mentalhealth: to highlight the gap between politicians’ and Ministers’ talk and action. For them it’s far less #timetotalk and much more #timetoact.


[1] – Source for this is Table 3.4 in HSCIC’s 2013/14 social services expenditure report (pdf). The table above represents adult social care spending for people aged 18-64; the situation is replicated for people aged 65+ as well. To see the equivalent figures in the health system for the last 3 years see Andy McNicoll’s excellent analysis here.

[2] – See, for example, Nick Clegg’s mental health taskforce or Norman Lamb “pursuing for the last six months or so” out-of-area placements for people with serious mental health problems (presumably in the same way they’ve been pursuing for the last three years or so the number of people with learning disabilities in specialist inpatient units with, ahem, such success.)

Personalisation, S117 aftercare, out-of-area placements and George Clooney

Image via Cascade Fellows
Image via Cascade Fellows

A significant component of the personalisation agenda fundamentally challenges and changes where money goes as a result of the different choices people make about achieving what they want. This is rightly so, for “if you always do what you’ve always done, you’ll always get what you’ve always got.”

We know some pretty good numbers about how much money is spent in the social care system through Direct Payments. They show that the scale of spend through Direct Payments against all social care expenditure is growing, but small[1].

Does this mean that personalisation has failed? No. But what does it mean?

There have undoubtedly been compromises and manifestations of what was originally intended, meaning personalisation hasn’t always translated into what it was hoped and intended it would. For example, resource allocation systems and panel processes have become unwelcome norms. (We should remember that money was only ever one aspect of personalisation.)

Status Quo
Image via EIL

But in any change that fundamentally disrupts, or has the potential to disrupt the status quo, other forces – invisible or not – will always play their role. These include organisations who benefit most from the status quo and have literally vested interests in maintaining it. This is, I think, one of the more powerful reasons why personalisation in mental health is still taking hold rather than taken hold, as seen through the Direct Payment numbers.

In mental health the status quo is a particular challenge because the overwhelming destination of money is in the health system. For health organisations dealing with mental health it tends to be more a question of how much money they’ll get rather than whether they’ll get it[2].

Organisations generally exist in order to protect what they are currently doing. The personalisation agenda in mental health is thus a fundamental challenge to health organisations and the status quo. How do we therefore bridge the chasm of effecting the change personalisation seeks to achieve by working with and through health organisations?

Rather than just mechanisms and processes, we need to think explicitly and tactically. We need to speak in a language that others will understand, and recognise their existing, actual starting point and create a path from that point to where we want things to be in the future.

Start where you are. Use what you have. Do what you can – Arthur Ashe (via @areynolds67)

To change the status quo you need a variety of approaches. Policy and legislation through government have their role. So does compulsion through regulation. Peer or public pressure is another, as is the drive to maintain existing levels of business.

A useful tactical way to change the status quo is to align agendas.

I’ve often talked about the public policy idea of the Advocacy Coalition Framework[3]. Here, people with often very different perspectives share a common goal and form a coalition through which they advocate for particular outcomes. They align their agendas. Changes in the treatment of domestic violence are a good example of a successful Advocacy Coalition approach, bringing together feminists and the police as unlikely allies.

Another way of thinking of this is by imagining being George Clooney’s character in Up In The Air. He specialises in making people redundant, but how he frames it is not as an opportunity to carry on doing what’s always been done, but to take the opportunity to do something different. Despite it being painful, and a process that doesn’t always work for everyone, what Clooney’s character does is align one set of objectives – the company’s, wishing to make people redundant – with another – the person’s, wanting to make a different future[4].

What if we apply this to personalisation in, say, the area of mental health? I think it can be strongly argued that personalisation is a solution to two existing problems that health organisations (and others) are grappling with: Section 117 aftercare and out-of-area placements.

Without going into the details here, key elements of the personalisation agenda, if done properly, would directly address causes or effects of problems related to S117 aftercare or out-of-area placements. Personalised funding, integrated at the level of the individual, with a clear plan that matches assessed need with outcomes and choice over how best to achieve those outcomes, helps to address a myriad of S117 aftercare problems. Good market development in an area, that enables supporting people at the right level at the right time, with good information and a focus on maintaining meaningful networks important to the person, directly addresses many of the problems of out-of-area placements.

By tactically aligning agendas through choosing to address issues around S117 aftercare and out-of-area placements using personalisation, there is an opportunity to normalise personalisation. This approach takes account of where health organisations currently are, but gives them a different set of tools for addressing the problems they face which has the added benefit of showing them personalisation works. It is undoubtedly tactical, and may well involve an element of compromise, but I’d strongly suggest it would help with where we want to get when it comes to personalisation.


[1] – See Figure 3.2 in HSCIC’s 2013/14 Personal Social Services Expenditure and Unit costs release (pdf)

[2] – Remember when NHS England imposed a 1.8% deflator on non-acute health services, including mental health, compared to a 1.5% deflator for acute services? The equivalent cut to local authority social care services – also covering mental health – has been 26% to date since 2010/11. For more details see LGA’s Adult social care funding: 2014 state of the nation report

[3] – I can’t recommend highly enough Paul Cairney’s 1,000-word summary of the Advocacy Coalition Framework

[4] – (Spoiler) We should note that Clooney’s character is a bit of a schmuck for most of the film, but he comes good in the end.

What a silly thing the “Daily Mail test” is

Image via The Poke
Image via The Poke

At an otherwise interesting event last year, the familiar canary of the “Daily Mail test” came up.

For those lucky enough not to have come across this, this test introduces the idea that decisions should be taken with at least some consideration to the question of how it would look if the Daily Mail (or some other venerable vessel) ran the story on their front page.

If you give it a moment’s thought the “Daily Mail test” is clearly silly, especially in the world of social care we’re particularly interested in here.

I can think of at least three reasons why this is the case – one specific, and two general:

Specific: When has the Daily Mail actually covered anything on social care?

General one: Social care gets such little coverage that having it on the front page of any newspaper is an opportunity, not a threat

General two: Why do we care what the Daily Mail thinks?

Recognising, though, that organisations make decisions based on reputation and risk more often than not, here’s a suggestion: what we should do is not sit and make decisions based on a hypothetical possibility of some press coverage that might come to pass. Instead we should proactively capture and share stories, success and progress and how these things make a positive difference to people’s lives.